Aims of the session

1. Aims of the session • Types of patients • Assessment • Bowel management • Types of anal irrigation • Case studies • Outcomes and issues

2. Bowel problems • Slow transit • Chronic constipation • Obstructed defaecation • Faecal incontinence • Spinal problems • Head injury • Multiple Sclerosis

3. MS • 85,000 MS sufferers in UK (Fowler et al 2008) • 3:1 women:men (Fowler et al 2008) • 75% will experience constipation and/or faecal incontinence (MS Society 2010) • 50% incontinent of faeces in past 3 months • 20-30% incontinent of faeces at least once a week. (Krogh & Christensen 2009)

4. Diet and fluids Exercise if possible Osmotic laxatives Stimulant laxatives Suppositories/enemas Irrigation Anal irrigation recommended by NICE (2007) Bowel management

5. Luxury of time Comfort of own home Holistic assessment Medical and surgical history Medication DVD and information Home visit

6. Types of irrigation • Cone system • Electrical pump system • Rectal catheter pump system

7. Pump cone system Qufora • Patient holds cone in place • Performed on toilet • Water and faeces empty into toilet

8. Biotrol pump Patient holds cone in place Pump assists flow of water Performed on toilet Water and faeces empty into toilet Pump Cone system

9. Catheter system Peristeen • Rectal catheter held in place by balloon • Water pumped into bowel • Performed on the toilet • Water and faeces empty into toilet when balloon released

10. Referral pathway • Cone system – assessment by suitably trained healthcare professional • Rectal catheter system – must be assessed by a doctor with appropriate knowledge and skills before commencing irrigation • MDA alert – risk of perforation • 1:100,000 – minimal risk

11. Never teach irrigation to the following patients: • Acute inflammatory bowel disease • Known obstructing rectal or colonic mass • Rectal or colonic surgical anastamosis within the last 6 months • Severe cognitive impairment (unless tolerated and carer able to supervise/administer) • Pregnant or breastfeeding

12. Proceed with caution • Spinal cord injury at or above T6 – risk of autonomic dysreflexia – 1st two irrigations must be supervised • Unstable metabolic conditions – renal or liver disease • Physical or cognitive disability/mental or emotional disorder • Anorectal conditions that cause pain or bleeding (e.g anal fissure, 3rd degree haemorrhoids)

13. Proceed with caution • Pregnant or planning pregnancy • Any bowel or abdominal surgery within the last 6 months • Acute diarrhoea • Anal fissure • Large haemorrhoids that bleed easily • Past pelvic radiotherapy which has caused bowel problems • Severe diverticular disease • Rectal medications for other diseases • Congestive cardiac failure • Anal surgery within the past 6 months

14. Home visit • Ensure exclusion criteria discussed • Ensure risks and benefits discussed • Demonstrate kit • Documentation and consent • Patient performs irrigation • Information and re-ordering • Contact details • Follow-up

15. Positive impact • Reduced toileting time • Clean and quick • Improved confidence • Quality of life • The word gets round! • Check suitability first

16. Acceptance Not for everyone Confidence Dexterity Frequency of use Abdominal cramps Volume of water Balloons bursting Catheter falling out Leakage of water Support from companies Issues encountered

17. Sally age 52 • MS diagnosed 15 years ago • Our patient 2 years for bladder symptoms • Disclosed bowel problems • Occasional faecal incontinence • Constipation • 3 hours a day bowel care • Using laxatives and suppositories • Digital stimulation and removal

18. Sally • Reluctant to go out • Depressed and isolated • Life revolved around bladder and bowels • Thought nothing else was available • DVD and information about irrigation system

19. Sally • New lease of life • Half hour bowel care • Reduced laxative use • Increased activity • Forgets about bowels for rest of day • Happier • Massive impact on QOL

20. Thank you Maria Moor Continence Nurse Specialist 01274 322171 Maria Moor@bradford.nhs.uk